The document discusses the roles and responsibilities of governing boards, medical staff, and chief executive officers in healthcare organizations. It explains that governing boards are ultimately responsible for quality of care and finances, while medical staff oversee patient care quality and are accountable to the board. Medical staff bylaws outline obligations and are legally binding. Credentialing of medical staff protects patients and the organization. Due process is required for disciplinary actions affecting privileges or employment.

1. © 2017 American Health Information Management Association© 2017 American Health Information Management Association
Chapter 19: Medical Staff
Fundamentals of Law for Health
Informatics and Information
Management, Third Edition

2. © 2017 American Health Information Management Association
Governing Board (Board of
Directors)
• Ultimate responsibility for the quality of
care and financial well-being of the
healthcare organization
• Controlling authority for healthcare
organization
• Responsible for providing adequate staff

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Responsibilities of the
Governing Board
• Define the mission and purpose of the organization
• Select (hire) the chief executive officer (CEO)
• Review and support the CEO
• Ensure adequate organization planning
• Ensure the financial health of the organization (fiduciary duty)
• Ensure the quality of patient care
• Enhance the public image of the organization
• Serve as a court of appeals (for due process of the medical
staff)
• Assess the performance of the board of directors (BOD)

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Chief Executive Officer (CEO)
• Reports directly to governing board
• Works with medical staff to provide patient
care
• Responsible for overall management of
healthcare facility

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Medical Staff
• Responsible for oversight of quality of
patient care
• Directly accountable to governing board
• Governed by medical staff bylaws

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Medical Staff Bylaws
• Must be voted on by medical staff and
approved by governing board
• Bylaws outline medical staff obligations
• Considered a contract; legally binding in most
states
• Requirement for a medical staff is found in
– Hospital licensure regulations
– Medical Conditions of Participation
– Joint Commission accreditation standards

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The Joint Commission and
Medical Staff Standards
• Requires medical staff bylaws address self-
governance and accountability to governing
body
• Medical staff must operate under direction of
medical staff officers and committee structure
• Officers
– President, president-elect, chief of staff, vice chief
of staff
– Others may be appointed depending on
organization size

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Medical Staff Committees
• Executive committee
– Elected members of the medical staff, act on
its behalf, have voting rights
• If hospitals use Joint Commission
accreditation for “deemed status” in lieu of
Medicare or Medicaid certification process,
executive committee is required

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Typical Medical Staff
Committees
• Credentials
• Bylaws
• Continuing medical
education
• Nominating
• Professional affairs
• Clinical oversight
• Electronic health
record
• Quality improvement
• Infection control
• Pharmacy and
therapeutics
May be many more committees depending on type
of hospital

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Categories of Medical Staff
• Active
• Associate
• Courtesy
• Consulting
• Honorary
• Affiliate

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Medical Staff Credentialing
• Process of reviewing and validating qualifications
of physicians and other licensed practitioners for
granting medical staff membership
• Credentialing protects
– Public from professional incompetence
– Medical staff from working with incompetent
professionals
– Facility form liability due to providing inadequate care
– Right of medical staff from unfair restrictions on their
practice

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Joining the Medical Staff
• Must have rigorous application process in
place
• Primary verification process—Must verify
from primary source information on the
application
– For example, request certified transcript rather
than copy
• Credentials verification organization—
Company that provides verification service to
organization

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Joining the Medical Staff
(continued)
• Kadlec Medical Center v. Lakeview
Anesthesia Associates
– Louisiana federal court found hospitals have a
duty to disclose information about current and
former medical staff members to other
healthcare providers to protect future patients
when physician moves on.

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Joining the Medical Staff
(continued)
• Must query National Practitioner Data Bank
(NPBD) for any adverse actions taken
against practitioner at time of initial
application and every two years thereafter
• Should check Office of Inspector General’s
list of individuals and organizations excluded
from participating in Medicare, Medicaid, or
other federal program
– Civil penalties may be assessed if an excluded
practitioner is hired

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Determination of Clinical
Privileges
• Similar to process for medical staff
application, usually applies for privileges at
same time
• Expected competencies include
– Patient care, medical/clinical knowledge,
practice-based learning and improvement,
interpersonal communication skills,
professionalism, and systems-based practice

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Determination of Clinical
Privileges (continued)
• Determining of privileges also requires
continuing evaluation
– Focused professional practice evaluation
• Time-limited period in which organization
evaluates and determines practitioner’s
professional performance
– Ongoing professional practice evaluation
• Documenting data on credentialed staff on an
ongoing basis rather than on two-year cycle

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Medical Staff Duties and Rights
• Duty to provide patient care, treatment, and
service as needed to patients
• Must respond to calls from emergency dept. and
provide consultation services when appropriate
– Potential area for sanction if physician does not
• Maybe required to be “on call”
• Must serve and attend medical staff committees
• If teaching facility, then required to supervise
fellows, residents, and interns

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Health Record Integrity and
Documentation Requirements
• Rules for timely completion of records,
legibility requirements, communication and
coordination of care with others,
completion of reports (for example, history
and physical, progress notes, operative
report)
• Failure to comply may lead to disciplinary
action

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Disciplinary Actions and
Suspensions
• Procedures must be in place to deal with
disciplinary actions and suspensions
– Revoke admitting privileges or time in
operating room
• Action must be reported to NPDB

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Due Process
• Required in hiring, disciplinary process or
other actions affecting medical staff privileges
or employment
• Two elements of due process
– Substantive: Guarantees laws are fair,
reasonable, and not arbitrary; allows for
challenges to a law’s content and substance
– Procedural: Government shall not take a person’s
life, liberty, or property without due process of law

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Due Process (continued)
• Places restrictions on government and public
facilities and may also apply to private
organizations that perform public functions or
involved in state action
• Hallmark of legal system, but is increasingly
being exercised outside of court system
• Healthcare organizations are using policies
and procedures to spell out adherence to due
process

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Additional Consideration:
Antitrust Laws
• Watch for anticompetitive conduct that
violates antitrust laws including
excessively restrictive noncompete
clauses
• Beware of “economic credentialing,” i.e.,
granting or denying privileges based on
financial indicators rather than factors
related to clinical performance

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Case Law Every HIM
Professional Should Know
• Darling v. Charleston Community
Memorial Hospital
• Kadlec Medical Center v. Lakeview
Anesthesia Associates