Career Planning
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Starting With Your New Practice
Understanding Your Medical Staff Bylaws
Regardless whether your new practice is an academic program, private hospital, or regional health system, it is important to understand the medical staff governance model used by these organizations.
This governance model dictates the scope of practice, qualifications, performance standards, credentialing, and reasons for possible suspension of your hospital privileges.
Regardless whether your new practice is an academic program, private hospital, or regional health system, it is important to understand the medical staff governance model used by these organizations.
This governance model dictates the scope of practice, qualifications, performance standards, credentialing, and reasons for possible suspension of your hospital privileges.
Here is some helpful information regarding hospital medical staff governance:
What is hospital medical staff?
Every hospital has one. But what does it mean? The term medical staff simply refers to every licensed provider with privileges to provide patient care at the hospital.
Collectively, each and every physician make up the organizing body of licensed physicians. This is called the medical staff and they are governed by a set of bylaws broadly dictating the scope of care, standards of practice, performance requirements, and other “rules” to be followed.
Why is there an organizing body?
The purpose behind this model is to ensure that standards in practice, performance, requisite training, education, and licensing are all defined to ensure that patients are treated and cared for appropriately and without harm.
The purpose of the Credentials Committee, to whom you will have to submit your application, will be to review your file, ensure the appropriate background checks have been completed, and ultimately, approve your requested privileges.
This will happen every two years as an ongoing physician performance evaluation (OPPE). There are actually several committees and departments with formally elected and designated chairs to execute the governance requirements outlined within the bylaws.
Most of this work will happen without your involvement or even awareness in some cases, but it is helpful to be understand its purpose.
What should I review when starting with a new practice?
There are several components of the medical staff bylaws you should familiarize yourself with:
Department Meeting Requirements
You will be assigned a department and/or section and will be required to meet a minimum number for meeting attendance. This will be outlined in the bylaws and is usually defined as a percentage of the total number of meetings scheduled throughout the year.
Be sure you know how many you must attend. These are typically scheduled consistently and regularly throughout the year far in advance.
Aside from being required, these meetings are important to attend since this is where administration, your peers and colleagues, physicians leaders, etc. will communicate important information on an ongoing basis. Decisions or changes impacting the department or section will also be brought here for discussion, awareness, and in many situations, formal voting approval.
If you have a professional interest in leadership or influencing changes beyond your day-to-day practice and immediate group, you can become involved in a variety of initiatives and roles both formally and informally.
Call Requirements
Response times will be outlined in the bylaws. These expectations will be set within your group and you will know the specifics of your call schedule, but it is also good to know that formal rules and expectations are outlined and governed by the medical staff.
This is generally in place for situations when call response times or expectations are not met. The bylaws define the standard and if there are any issues with a physician or group not meeting the requirements, there is a recourse and performance improvement process outlined.
Performance Standards
If there is an issue with performance, the course of action may fall to the bylaws and the governance structure. Consider the fact that this is the group that approved your privileges. They also have the authority to remove them as well.
For employed physicians, you will be held to both the employment contract terms and conditions, as well as medical staff bylaws terms and conditions. It is important to ensure that these do not contradict one another.
As a practicing physician, it is unlikely that you will encounter disciplinary actions related to either of these situations, but it is nonetheless helpful to be mindful of the “rules” related to not only your employment but your hospital privileges as well.
Ongoing Physician Performance Evaluation (OPPE)
With certain hospital regulatory and accreditation requirements, physicians on staff have to have a formal evaluation completed at least every eight months, referred to as the OPPE. The purpose is to prevent patient harm by providing a process for checking and formally evaluating each physicians’ performance in an ongoing manner BEFORE they are recredentialed every two years.
While the general rules are the same for each and every physician and department, the details in terms of process, performance requirements, formal sign-off, etc. will vary from department to department.
Upon starting with a new practice, be sure to know where and how to access your medical staff bylaws and definitely review the various “rules” you will be required to follow.
