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Nick Healey
Hello and welcome to Beyond the Bylaws: The Medical Staff Show. This is Husch Blackwell LLP's podcast covering the legal and regulatory aspects of hospital medical staffs. We're focusing on the important but sometimes confusing world of medical staff legal issues. I'm Nick Healey, a health care regulatory partner at Husch Blackwell, and I am in my third decade of working with hospital medical staffs.
00;00;25;00 - 00;00;56;16
Nick Healey
Before we dive in, I'd like to note that nothing in this podcast constitutes legal advice, and the views expressed in this podcast are mine or those of our special guests and not those of Husch Blackwell. Thanks for tuning in for part two of our medical staff bylaws episode. This episode is the one in which we cover more specific issues that come up in the medical staff bylaws, provisions that you'll commonly find in medical staff bylaws, drafting tips, ways to avoid common problems, and other fun topics.
00;00;56;19 - 00;01;15;13
Nick Healey
Okay, so let's actually turn to big topics that really should be covered in the bylaws. And we can go through these. And I just want to talk about I want to mention what needs to be in the bylaws. And then we can talk about specific parts of them. But one of the crucial parts I think we've already covered, which is, you know, the priority of bylaws, rules and regulations and policies.
00;01;15;13 - 00;01;48;24
Nick Healey
And I think we would all agree here today that treating the bylaws like, you know, a constitution that, contains the basic steps or processes, the basic qualifications for membership, you know, the basic principles by which the medical staff organizes itself. And in my view, particularly some statement that recognizes and states the relationship of the medical staff to the other stakeholders, the really important stakeholders in the organization, administration and the governing body.
00;01;48;26 - 00;02;12;13
Nick Healey
I've seen a lot of medical set bylaws that don't have that. I always put that in. I think that's actually really important, both to remind the medical staff that there are other stakeholders, that they have a very specific job under the conditions participation. They are delegated responsibility for the quality of care in the hospital. And that that really is the context in which the rest of the bylaws flow.
00;02;12;13 - 00;02;32;27
Nick Healey
You know, they all serve that purpose of ensuring that the medical staff can fulfill its obligation to the governing body to be responsible for quality of care. And I also like to put in there, you know, that their relationship, but their relationship to the administration and that the administration has a separate mandate from the governing body, that they're intended to be co-equal.
00;02;33;00 - 00;02;37;24
Nick Healey
And I'm curious, Ellee, do you tend to put that kind of a statement in there? Do you tend not to.
00;02;37;26 - 00;03;14;06
Ellee Cochran
You know, I don't know that, frankly. I'm glad we're talking about it because, I don't know that I've been as intentional in the past of making sure something like that is in there, but I think it's a really good idea, and I really like it. So now I will, I, I think I totally agree. I have seen a lot of issues in the past where, medical staff, there's just a confusion of how it's supposed to go and like, what is your what is the role and where, how decisions are supposed to go and what everybody's relationship is to each other and why, like I've done a bunch of trainings to
00;03;14;06 - 00;03;40;05
Ellee Cochran
explain to the medical staff like, hey, this is why it's structured this way is because the Medicare conditions are participation. And then accordingly, your accrediting body, whatever it is, requires it to be this way. This is why we do it this way. And they're like, oh, okay. And that context, I totally agree. Reading everything else with and having that context and background, it's just really helpful to be like, oh, this is why.
00;03;40;08 - 00;03;44;21
Ellee Cochran
Yeah, yeah, I should do that more. So thanks for the tip.
00;03;44;23 - 00;04;03;24
Nick Healey
I yeah, it's just been something that I found has been really helpful. I mean, because I don't know that medical staff members and particularly people who are tasked with reviewing bylaws, get a lot of training on exactly why they're doing what they've been asked to do. And I think it is actually a really important part. Melanie, do you guys do that?
00;04;03;26 - 00;04;22;14
Melanie Durfee
I think my realizes are pretty clear on the relationship between the medical staff and the board of trustees, but I think that's a fantastic idea to add some additional language about the relationship with administration and how all of those pieces fit together. And I to look and see if we can make some changes. There.
00;04;22;16 - 00;04;48;12
Nick Healey
One of the other things, with respect to other stakeholders that has, come up over the years is including some kind of I hate to say, dispute making dispute resolution mechanism when there are disputes between administration and medical staff or administration and medical staff and the governing body. But is that something you typically see in bylaws? I put it in a number of bylaws.
00;04;48;14 - 00;05;01;19
Nick Healey
In some situations, it hasn't been important to the medical staff, but some kind of joint conference committee in which they can hash these things out, I think is a really helpful mechanism for that. And I'm curious about what your thoughts are on that.
00;05;01;22 - 00;05;33;14
Ellee Cochran
I think it can be helpful. I very rarely see it if I'm being honest. Like, yeah, I very rarely see it. California requires it. I remember doing a set of California bylaws at one time and looking at that, and there they do require it. The Joint Commission has like, a if the a requirement to have some sort of mediation body on disagreements over the bylaws or amendments to the bylaws or something, it's just very narrow, very specific.
00;05;33;17 - 00;05;55;04
Ellee Cochran
I've never seen it be that helpful. So honestly, yeah, I think that having it's rare when that comes up, in my experience. But it does come up, you know, maybe not that rare, actually, no. I think about it. Disagreements between the governing body and the medical staff or administration and the Michaels, all of that and some sort of mechanism I think could be really helpful, but I very rarely see it.
00;05;55;07 - 00;05;57;11
Nick Healey
Yeah. Melanie, what do you guys do?
00;05;57;13 - 00;06;24;08
Melanie Durfee
Yeah, I have a I do have a section in the bylaws for conflict resolution. It's brief. And it does talk about the, if the, medical staff and the board of trustees cannot agree on amendments to the bylaws, it's it's in line with that. It does talk about outlines, a process for conferencing together, meeting together to see if they can work through it and talk through their differences of opinion on and, amendments.
00;06;24;11 - 00;06;33;25
Melanie Durfee
I don't have anything in there about conflicts between administration and the medical staff, but that does come up, and it's probably a very good thing to add.
00;06;33;28 - 00;06;55;26
Nick Healey
Yeah, I've actually also seen it between or triggered between, for conflicts between departments as well as between departments and committee. I mean, an overall medical staff dispute resolution process between different elements of the medical staff. And I haven't seen it triggered very often. But, I always think it's a good thing to include in there from a structural perspective.
00;06;55;28 - 00;07;20;13
Nick Healey
So just a suggestion, I guess if anyone listening, maybe having those issues and, and needs a, a mechanism that's one to think about. Okay. So another critical thing, qualifications for membership and clinical privileges. So here I'm kind of curious about, you guys experience with respect to how detailed you get. I mean, you need to outline the categories.
00;07;20;13 - 00;07;45;05
Nick Healey
Again, the Joint Commission requires that you have all of the categories of medical staff membership outlined as well as the credentialing and, and, privileging processes outlined. I'm curious about how detailed you guys get in the medical staff bylaws. With respect to what the qualifications for medical staff membership are, versus privileges in each category. So, Melanie, what about you?
00;07;45;06 - 00;07;47;05
Nick Healey
What are your bylaws say about that?
00;07;47;08 - 00;08;09;03
Melanie Durfee
It's still a it's fairly high level at the bylaws. Level, it does. We go into some detail about, for example, like number of patient contacts that you have to have for each of the different categories or who fits into each of those categories. And why. Beyond that, it also talks about responsibilities and prerogatives. But it's it's more of a summary at the bylaws level.
00;08;09;03 - 00;08;20;13
Melanie Durfee
And then like the credentialing policy or the other documents that are governing processing applicants to make sure that they qualify are much more detailed.
00;08;20;15 - 00;08;49;00
Nick Healey
Yeah. One of the one of the big issues that when going through these bylaws, drafting exercises, I still get some medical staffs that want to include some elements of privileges in certain categories. So you'll get like for active medical staff membership, the active medical staff membership category, you'll get people who want to put in the the right to admit patients to the hospital goes in with is a prerogative of active medical staff membership.
00;08;49;02 - 00;09;12;01
Nick Healey
I always discourage that because in my mind, medical staff membership is a political issue. It, you know, dictates who gets to be on committees, who's eligible to be an officer, who has the right to vote for certain things and privileges are a different issue. And the right to admit is a privilege. It's not necessarily a right, that goes along with medical staff membership.
00;09;12;04 - 00;09;18;27
Nick Healey
So I always try to separate those two issues in the bylaws. Ellee thoughts on that?
00;09;19;00 - 00;09;42;06
Ellee Cochran
Yeah, no, I actually think that's a good perspective. And it's it's a really like, detailed, nuanced one that you're not going to find that anywhere. Right? You're not going to find that requirement in the CPAs or the accrediting bodies requirements. It's like, how things actually operate. So I like that perspective. Actually, I hadn't thought of it that way, but I've seen a lot of questions come up about that.
00;09;42;08 - 00;09;52;25
Ellee Cochran
Requirements for admission and this and that, especially when you get to like position on hospitals that are grandfathered in. That can be very touchy.
00;09;52;27 - 00;10;24;22
Nick Healey
Absolutely. Can I I'm curious as well, with respect to requirements for privileging, do you either of you ever include in the bylaws or do you, you know, leave it for privilege sheets, any requirements for specific privileges, qualifications for, being able to hold certain privileges like in a couple of them, actually, I'll give you just one example, is in a lot of bylaws, they'll have, that in order to qualify for privileges, a house or a physician needs to have, an office within X number of miles of the house.
00;10;24;25 - 00;10;45;19
Nick Healey
Which, you know, having in the bylaws to me seems a little, as you said, prescriptive a little too detailed, because there are certain privileges that you may not need that. And it also goes to whether you're required to you have any patients in the hospital, whether you've made alternate arrangements to be in town when you have patients in the hospital, whether you're on call.
00;10;45;19 - 00;10;54;24
Nick Healey
So I'm curious if you guys still see that a lot or if you you know, you advise including it, but what's your thoughts on that? And Melanie, what do you think.
00;10;54;27 - 00;11;12;27
Melanie Durfee
That one in particular, the like the distance from the hospital that's addressed in a call policy for us. Like it. And if you have to take call and you're responsible to respond within X number of minutes, you need to live within X number of miles. That's all in call policy for us. I have seen it in the bylaws before.
00;11;12;27 - 00;11;16;28
Melanie Durfee
Not here, but I don't have it in my bylaws now.
00;11;17;00 - 00;11;38;03
Ellee Cochran
I think that's a better practice. Yeah. What? The way Melanie's hospital does it. I have seen it in the bylaws as well, with a lot of clients. And typically to use your term, what you just said, it's, a more of a political, it's a gatekeeping thing that they like to have in there as a qualification rather than the call, as is what I've seen.
00;11;38;04 - 00;11;38;29
Ellee Cochran
Yeah.
00;11;39;01 - 00;12;24;14
Nick Healey
It does make me a little concerned with the increased scrutiny of the FTC on, antitrust issues with hospitals. That something that is the condition of holding privileges at all would be, you know, isn't necessarily related to isn't as related to patient care's as it should be and probably explaining that badly. But but it seems like addressing it in a privileging policy or with respect to certain privileges and requiring that if you have, you know, people in the hospital or you, patients in the hospital or you're on call that you have to be, you know, able to respond within 30 minutes or something like that, that makes a lot more sense than requiring
00;12;24;14 - 00;12;39;17
Nick Healey
that somebody have a full time physical presence within a certain number of miles of the hospital. I would wonder in some situations whether, antitrust, regulatory agencies might have something to say about those sorts of things. Ellie, do you have any thoughts on that?
00;12;39;19 - 00;13;05;13
Ellee Cochran
I mean, maybe I think they have bigger fish to fry than, you know, frankly. So, but, you know, potentially, if somebody really wanted to make a stink about it, but, yeah. Yeah, I don't think people fail to sue. Sorry for, doctors when it comes to all that. So I don't know. You know, I, I, I could see an FTC saying like, oh, you're just using that to block trade.
00;13;05;16 - 00;13;14;02
Ellee Cochran
Which I think sometimes maybe is like an ulterior motive, but there are you can come up with legitimate reasons behind it. So, yeah.
00;13;14;04 - 00;13;38;23
Nick Healey
So yeah. Okay, so we've talked about categories of the medical stuff. Nurse practitioners and NPAs are obviously a hot topic for the medical staff as a whole across the country these days. And I'm curious, I know that the cops allow, peers and NPS to be members of the medical staff, depending on, state law. But I'm curious what you guys have seen.
00;13;38;23 - 00;13;52;28
Nick Healey
Do you see, MPs and peers allowed to be full members of the medical staff with the same political rights as physicians? Do you see them in a separate category with different political rights? Ellie, what are your thoughts on that and whether they should be?
00;13;53;01 - 00;14;19;09
Ellee Cochran
I typically do not see them as full members of the medical staff. In fact, I don't think I have any clients that have that often. You know, being honest, I don't think any of them do. They're typically allied health professionals, with a little bit more limited rights than full members. And whether they should or shouldn't, I mean, I think that just really depends on the hospital, you know, and the dynamics of the hospital.
00;14;19;09 - 00;14;40;22
Ellee Cochran
And also, you know, I'm not a medical provider, so I don't know that I feel like, comfortable saying they should or shouldn't, you know, but I can see it being tough in certain circumstances and dynamics and then other and in other certain circumstances and dynamics. I think it's perfectly normal. It I mean, like all workplaces, I think all hospitals have like a certain vibe.
00;14;40;22 - 00;14;51;13
Ellee Cochran
And how things though there and things work and whether they are given that position on the medical staff kind of depends on how they operate.
00;14;51;16 - 00;14;52;07
Nick Healey
So I'm going to.
00;14;52;07 - 00;14;53;27
Ellee Cochran
Get that careful enough. Yeah.
00;14;53;27 - 00;15;12;06
Nick Healey
Very funny, I appreciate that. But, you've also you've also clued me in to the first item of merch that beyond the bylaws, is going to offer in our online merch store, which is, a a t shirt that says bylaws, bods.
00;15;12;08 - 00;15;13;11
Ellee Cochran
Bylaws, lists.
00;15;13;13 - 00;15;21;20
Nick Healey
All right. Like that. I think that's great. Melanie, what's what's your experience with with peers and MPs on the on the medical stuff? Yes.
00;15;21;20 - 00;15;41;20
Melanie Durfee
Now, they are not considered members of the medical staff here, but we did during that last speaker review, our medical staff, they discussed it at length during that review, and they weren't quite ready to take that leap to, to make them, members of the medical staff. But they did take a lot of steps to, involve them further.
00;15;41;20 - 00;15;57;07
Melanie Durfee
We changed quite a bit of like, what committees they can sit on and what other ways that they can participate with the medical staff without being full members of the medical staff. And I think that our AP staff has appreciated that. Being more involved.
00;15;57;10 - 00;16;02;26
Nick Healey
Do you have been sit on credentials or peer review or in the NSC?
00;16;02;29 - 00;16;23;20
Melanie Durfee
You have I don't have one currently on. See, but the bylaws do say that an AP member may be appointed to NSC. I do currently have one on NSC and our peer review committee on our wellness committee. And, it seems like there's a couple of other smaller committees, too, that have AP members down.
00;16;23;26 - 00;16;49;01
Nick Healey
I know that the the argument that, physicians usually make the APS shouldn't sit on credentials or peer review or the NSC itself. Is that, an EP or a non physician shouldn't be in a position to judge the care provided by a physician because they don't have the they don't have the same training. I think they would often say adequate training.
00;16;49;03 - 00;16;55;17
Nick Healey
But I'm going to say the same training and I'm just curious leg do you do you hear that to.
00;16;55;19 - 00;16;57;29
Ellee Cochran
That they have the same training.
00;16;58;01 - 00;17;10;29
Nick Healey
No no, no. But they shouldn't sit on, on, committees or be in positions where they, are asked to judge the quality of care provided by a physician because they don't. Yeah.
00;17;11;02 - 00;17;34;01
Ellee Cochran
Yes, that's exactly it. Yeah. Yeah, I can there can be some territorial feelings, you know, about that. If. Gosh, it just depends, like I said, on the dynamics and the personalities involved, how collaborative they are, how much they rely on APS because some of them were like, oh my gosh, I would die without them. I want them here, you know, advising on all of this.
00;17;34;01 - 00;17;45;17
Ellee Cochran
And others are like, no, thank you. There's still a hierarchy, you know, if we're being totally honest and real. So I think yeah, I definitely think that's the dynamic.
00;17;45;19 - 00;17;49;23
Nick Healey
Yeah. I don't disagree with you that there's a perceived hierarchy. But I.
00;17;49;25 - 00;17;51;06
Ellee Cochran
Perceived as the right word.
00;17;51;06 - 00;18;15;11
Nick Healey
Yeah, yeah. I think that is changing, particularly in smaller hospitals, critical access hospitals, particularly where the I mean, in some situations and under the the conditions of participation for critical access hospitals, a physician only needs to be on the, you know, on the ground at the hospital every two weeks. They have to be contact with the hospital more frequently, but they only actually have to be in the hospital every two weeks.
00;18;15;11 - 00;18;43;22
Nick Healey
And you you may have, you know, apps that are essentially running the the hospital or running the patient care in the hospital. So, you know, I think, in smaller hospitals where there's a huge role for apps, then I think there's a lot more argument that a well-functioning medical staff really does need to have more participation, political participation by people or the medical staff falls apart, to be honest.
00;18;43;22 - 00;19;06;27
Nick Healey
So that would be a really interesting, situation to monitor as time goes on. Because, you know, we are in a physician shortage. We have been for a long time apps. The number of apps on the ground are increasing, and in some hospitals, you know, there may be more apps than physicians. So, you know, I think it is definitely something to to review.
00;19;06;29 - 00;19;40;07
Nick Healey
As time goes on. So one of the other really important things to have in the bylaws is, is medical staff leadership. And a description of the, leadership, as you said, hierarchy. Ellie, from, accreditation or a, legal perspective, there's a ton of flexibility with boxes, hospitals, the co-op say that you have to have a, physician performing certain functions, with respect to patient care, that essentially make them a medical director.
00;19;40;07 - 00;20;01;12
Nick Healey
And in some hospitals, that medical director is also the chief of staff. But the acute care hospital cops just say that there has to be essentially a chief of staff function or a president of the medical staff function, which can be, an MD, D.O. or a podiatrist or a dentist. I guess I've never seen a dentist or a podiatrist be a chief of staff.
00;20;01;16 - 00;20;22;13
Nick Healey
Ellie shaking her head. So I'm assuming that you haven't either. But this is something in which you have, you know, a lot of flexibility in how to design the leadership of the medical staff. And my experience has been that you, you basically have, a chief of the medical staff, the MSE, and then you have different, you know, committees flowing down from there.
00;20;22;16 - 00;20;26;28
Nick Healey
Ellie, I'm curious if you've seen other other staff, other structures.
00;20;27;01 - 00;20;52;08
Ellee Cochran
No, I have not yet. But it's really it's remarkable, I always say about like how standardized everything is. And, you know, I wasn't practicing at the time, but I think all of that, I actually kind of like, this is really nerdy. But I feel like you would appreciate it. Like, maybe you and I could, like, write some sort of, like, book or some some sort of, like, thing or history article about, like, the history of that and why they're like that.
00;20;52;08 - 00;21;13;22
Ellee Cochran
Like, was it Greely? Was it. Who was it that created this, like set of bylaws that everybody uses from the 1980s? You know what I mean? Like what what is this structure and who did it and who's responsible. It's just we gotta name this person. We got to, like, do some research and figure it out because they're all the same, you know, within reason.
00;21;13;22 - 00;21;28;29
Ellee Cochran
Right? There's there's some wiggle room here and there. But like with your sec, with your chief, vice chief, all of those things, I don't know, it's kind of fascinating to me how across the country there are no rules. Rules. But yet everybody does the same thing.
00;21;29;01 - 00;21;54;28
Nick Healey
Yeah. I mean, I have said in some situations that, the medical staff bylaws can almost write themselves by the weight of tradition and history and legal requirements that go into them. Right? There's only so many ways to skin that particular cat. Right, Melanie, to follow on from Ellie's comment, I'm curious if you've ever seen, you know, nontraditional structures for medical staff leadership that you, you've liked.
00;21;55;00 - 00;22;12;21
Melanie Durfee
I really haven't, Ellie made a good point. It is pretty standardized without maybe even being intentionally standardized to usually always the same medical staff. President or chief of staff. By Steve chairs of the committees, folks usually who makes up the leadership of the medical staff.
00;22;12;21 - 00;22;43;27
Nick Healey
I've also seen, and this is actually a variation that I've seen in a number of different places, that in a lot of situations, you'll have, seats on the NSC that are carved out for department heads. So it's more of a, I guess, representative democracy or, small, Republican, style of democracy, where you have, certain groups that vote for their representative to the NSC who then sit on the neck and make decisions on their behalf.
00;22;44;00 - 00;23;14;19
Nick Healey
I've also seen, Max that, you know, have members at large who were voted from voted on from the, you know, the body of the medical staff. So there are a lot of different ways to structure it in large medical staffs where there's a lot of departments or service lines, or specialties, there probably is a role for a more represented form of democracy as opposed to direct democracy and the medical staff voting for, you know, those people individually.
00;23;14;19 - 00;23;38;19
Nick Healey
But there are many, many ways to skin that particular cat. Okay. So going on I would do on to touch on quality improvement. So that is also a critical part of the bylaws to ensure that your quality improvement processes are at least outlined in their. Although often they're given pretty short shrift. In my experience, the bylaws rarely go into detail.
00;23;38;22 - 00;24;10;06
Nick Healey
Quality improvement, processes like peer review, FPO, PPE. But in your bylaws, do you guys, have those the quality improvement processes, do you have them outlined in detail, or do you just simply say these are committees which are responsible for these functions, and or individuals that are responsible for for the functions. And they will, you know, design processes to in, in rules or in, policies which will perform these functions.
00;24;10;09 - 00;24;29;11
Melanie Durfee
I would say the latter, is closer to what everybody loves. Are there outlines? Not a lot of detail that does lead to questions sometimes from medical staff leaders. They'll tell me, well, that's great. We're supposed to do x, y, z. But how how do we get there? What does that even mean?
00;24;29;11 - 00;24;53;13
Nick Healey
So, yeah. So just a couple of other things. We've actually touched on immunity, at least with respect to privileging and or privileges or the privilege that's applied to, medical staff information and quality information. One of the other things I think is really important to have in the bylaws is a recitation of the the statutory immunity that applies to medical staffs when they are doing medical staff work.
00;24;53;13 - 00;25;08;15
Nick Healey
So immunity from liability for being sued for peer review or those kind of things, is that something you guys have in your bylaws? Is it incredibly detailed if you do and or is it just a recitation that, you know, immunity may may apply?
00;25;08;18 - 00;25;42;22
Melanie Durfee
I do have that in my bylaws. I wouldn't say that it's overly complicated or detailed. You know, just talking about if it were action or taken in good faith and, within the confines of policies and procedures of the hospital and the rules and regulations that govern that. But there is an immunity afforded, I think it's beneficial because I have had many physician leaders come into their positions feeling like they had to walk on eggshells or be very careful about what they did or what they said because they had heard, oh, I could I might be able to get sued for this.
00;25;42;22 - 00;25;58;06
Melanie Durfee
Are you sure that I can do this? Are you sure that I can review this and say what? What I'm actually seeing here, without getting myself into trouble. So it's beneficial to have that in there for sure and have those conversations with those committees that are, participating in reviews on a pretty regular basis.
00;25;58;12 - 00;26;21;18
Nick Healey
Well, and it's interesting you say that about medical staff leaders who have heard that kind of thing because, you know, I think this goes to Ellie's point, too, that there's, a significant weight of urban legends surrounding medical staff work, and that does drive a lot more, activity on the medical staff side than you'd you'd imagine it would in such an evidence based profession.
00;26;21;25 - 00;26;49;22
Nick Healey
Right. On is heard something from a friend, that happened to them at a place x amount of years ago. And and we want to avoid that. And, you know, sometimes that's absolutely appropriate. And sometimes it's like, no, that's not that's a couldn't have been the way it happened. Or if you dig into the story, it's not the way it happened or but you know, wouldn't happen anymore because it happened in 1984.
00;26;49;22 - 00;27;03;10
Nick Healey
And, you know, there have been significant legal changes since that. So, you know, urban legend actually is a really interesting factor in, in the medical staff world. And there will have to be a chapter in lionized book.
00;27;03;13 - 00;27;05;17
Melanie Durfee
Yes, for sure, it'll be a great one.
00;27;05;18 - 00;27;34;19
Nick Healey
Yeah. Okay. So last thing I want to touch on is, is, investigations and, and the peer review or corrective action process. And I do want to draw a distinction here between peer review in the context of, I mean, both are quality improvement, the peer review in the sense of having a medical staff committee review. Cases that fall out on a regular basis versus peer review in the sense of a true corrective action or disciplinary process.
00;27;34;19 - 00;28;02;22
Nick Healey
And peer review. Can encompass both, but it again, from an urban legend perspective, I have found that peer review proceedings, tend to be thought of as the the harsher disciplinary part, when in fact peer review is a critical part of quality improvement and happens at levels far below the disciplinary process or far less, harsh than the disciplinary process.
00;28;02;25 - 00;28;38;05
Nick Healey
But, you know, there really is an important part of it having that, robust procedure and a well-established procedure in your bylaws for investigations and corrective action really is a critical part of the bylaws. And so every bylaws that I've seen, every set of bylaws, has a section detailing the steps that I have to go through for investigations and then situations in which, you know, the medical executive committee can recommend corrective action, and then a separate one for the fair hearing process, which again, the standard for the fair hearing process can be dictated by state law.
00;28;38;05 - 00;29;00;18
Nick Healey
But in almost every situation, you want to make sure that it complies with the basic requirements of the Health Care Quality Improvement Act, which outlines a series of of steps or qualifications that, your peer review or your corrective action process has to meet in order to ensure that you're covered by the immunity from liability for peer review.
00;29;00;18 - 00;29;24;21
Nick Healey
That's provided by the Health Care Quality Improvement Act. So a lot of them are pretty standard. And and again, to Ellie's point, that probably is wise because they're all intended to, to meet Hickox requirements. But in terms of, you know, the investigative process, there is a lot of flexibility in how you design those and the bylaws. And, you know, there's a role for constructive problem solving or, you know, before a formal investigation.
00;29;24;21 - 00;29;52;12
Nick Healey
There's also different routes you can take in the investigative process. So in terms of of constructive problem solving or or pre investigative action, which is ordinarily collegial intervention by other members of the medical staff, has that been a big part of you know, your experience in, in the medical staff world, have you seen that process used in a lot of situations, or is it, you know, rare today?
00;29;52;12 - 00;29;55;29
Nick Healey
Does your medical staff tend to go straight to the investigate of part?
00;29;56;06 - 00;30;21;27
Melanie Durfee
We use collegial interventions and some progressive steps like that pretty routinely. When we did our big revamp a few years ago, the process kind of changed. Like who was going to review initially and who's going to make that determination. But since we've gotten the new process down and our leadership committee, our medical staff leadership committee is who reviews most of the initial issues and makes the determination it's gone really well.
00;30;21;29 - 00;30;45;13
Melanie Durfee
Collegial interventions solve, a high percentage of problems that come up in the medical staff without ever having to go to that investigative or, a deeper dive into issues that are occurring. I've had it come up. Even that survey I had just last time, last time we had surveyors here, they were reviewing incident reports. The the hospital had received.
00;30;45;13 - 00;31;03;14
Melanie Durfee
There was a particular physician's name that came up and surveyor asked then when they came to do the medical staff review, she wanted to know all the details about what that investigative process looks like and what we did about this. And we were able to clearly articulate to her, here's what our process is. These are the progressive steps that we take.
00;31;03;14 - 00;31;25;18
Melanie Durfee
This was one that we just did a collegial intervention, reassigned another physician as kind of a mentor to help guide and, work with that physician to prevent any future issues or frustrations that were leading to the issues. And the survey was actually really impressed with that, the process and that we had it documented and that we were able to show how that collegial intervention had helped.
00;31;25;18 - 00;31;29;26
Melanie Durfee
And potentially solved the issue before it ever got to.
00;31;29;28 - 00;31;40;18
Nick Healey
So who who does the collegial intervention under your processes is the chief of staff or does the CMO chief medical Officer have a role? I'm curious.
00;31;40;20 - 00;32;07;19
Melanie Durfee
It can be any of those people. It is often so we're organized in service lines instead of departments, but it's usually either the service line chair or it can be the chief of staff and even the CMO. It depends, you know, like if it's an employed provider, sometimes it's the CMO on behalf of administration and kind of bridging that gap between this could get you in trouble on the employment side of things as well.
00;32;07;19 - 00;32;24;27
Melanie Durfee
And it's also been brought up with the medical staff. Sometimes the CMO is an appropriate. So it depends. But our the way that it's outlined in our policy, it can be any of those people. So the medical leadership Committee will talk about it first, will decide who the most appropriate person is depending on what the issue is through the collegial intervention.
00;32;24;27 - 00;32;33;12
Melanie Durfee
And then they report back to me or back to the committee at the next meeting, so that we have record of that for future if needed.
00;32;33;14 - 00;32;45;11
Nick Healey
So it always starts with the medical staff executive committee or whatever that medical staff committee is, and they can assign it out to different individuals depending on the circumstances. Is that right?
00;32;45;14 - 00;33;01;06
Melanie Durfee
Yep. It's, it's called in ours the Medical Leadership Committee. It's a subcommittee of MSA, and just a handful of the key leaders and they'll discuss those issues and then assign them out as needed to whoever. So, yeah, I like that.
00;33;01;08 - 00;33;24;08
Nick Healey
I like that idea of involving the CMO because in a lot of situations, the CMO kind of sits in a bit of a no man's land because they're always a physician. And, you know, often they're a member of the medical staff, but they don't usually have a, a firm role in the bylaws to do a lot of medical staff things.
00;33;24;08 - 00;33;41;11
Nick Healey
And, and I really like how you've identified them as a leader in the hospital that can do those kind of collegial interventions under the auspices of the medical staff. But I'm assuming there's still not a medical staff officer. Is that right?
00;33;41;14 - 00;33;41;26
Melanie Durfee
Correct.
00;33;42;03 - 00;34;04;26
Nick Healey
Yeah. So, you know, I really think that, in a lot of situations, bylaws, medical staff bylaws should acknowledge a role for the CMO. They don't always and I think that is a missed opportunity in a lot of situations because it it kind of, again, leaves them in a no man's land. And and it it can foster some.
00;34;05;01 - 00;34;26;09
Nick Healey
I don't know I want to say the sense of competition, but just confusion between the chief of staff and the CMO, between who is responsible for certain certain aspects of a medical staff, you know, corrective action or collegial intervention or quality improvement, those kind of things. So so I think that's a great way to to thread that needle.
00;34;26;09 - 00;34;45;07
Nick Healey
I really like that was going to stick in that category. But then I was sure it would attract a few to complain. So I like thread the needle better. Okay. Well, so that really is I mean, a, you know, kind of a shallow dive into the medical stat bylaws and elements that should be included in it, or in them.
00;34;45;11 - 00;35;23;22
Nick Healey
I mean, as I think to, you know, wrap up, the medical stat bylaws really are a critical, foundational document, and there is no one size fits all. I think you'd agree with that. Melanie. Yeah, me. And it really does take a lot of consideration by the medical staff in conjunction with other stakeholders, including administration and the board of, the governing board, whether it's board of directors or trustees or whatever it is, as to, you know, what should be in there, ultimately, it comes down to what in most situations, the medical staff and the board of, you know, governing board decide is appropriate.
00;35;23;22 - 00;35;51;18
Nick Healey
But there's a lot of stakeholders in the processes and, principles that are outlined in the medical staff that really do need to be carefully thought out and, you know, simply adopting a set of bylaws from another institution is rarely the right idea, in my experience. I think it really does require a lot of careful thought. So with that, Melanie, I really want to thank you for taking the time to be our special guest star today.
00;35;51;19 - 00;36;15;15
Nick Healey
Your perspectives have been really invaluable, and I really want to thank Ellee for, her contributions. She has a wealth of experience in medical staff issues, and, and I really enjoy working with her, so I, I'm grateful. Hats off to both of my special guests stars today. And I guess I want to thank everybody for tuning in to Beyond the Bylaws
00;36;15;17 - 00;36;25;21
Nick Healey
Husch Blackwell's medical staff podcast, and we will see you down the road. That was fun.
Ellee Cochran
That was fun.