BYLAWS, RULES AND REGULATIONS OF THE MEDICAL STAFF RICHARD L. ROUDEBUSH VA MEDICAL CENTER INDIANAPOLIS, INDIANA Revised January 2013 TABLE OF CONTENTS

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1 BYLAWS, RULES AND REGULATIONS OF THE MEDICAL STAFF RICHARD L. ROUDEBUSH VA MEDICAL CENTER INDIANAPOLIS, INDIANA Revised January 2013 TABLE OF CONTENTS Subject Page PREAMBLE 3 DEFINITIONS 3 ARTICLE I. NAME 4 ARTICLE II. PURPOSE 4 ARTICLE III. MEDICAL STAFF MEMBERSHIP 5 Section 3.01 Eligibility for Membership on the Medical Staff 5 Section 3.02 Qualifications for Medical Staff Membership & Clinical Privileges 5 Section 3.03 Code of Conduct 7 ARTICLE IV. ORGANIZATION OF THE MEDICAL STAFF 8 Section 4.01 Leaders 8 Section 4.02 Leadership 10 Section 4.03 Clinical Service 10 ARTICLE V. MEDICAL STAFF COMMITTEES 12 Section 5.01 General 12 Section 5.02 Executive Committee of the Medical Staff 13 Section 5.03 Committees of the Medical Staff 17 Section 5.04 Committee Records and Minutes 18 ARTICLE VI. MEDICAL STAFF MEETINGS 18 ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING 19 Section 7.01 General Provisions 19 Section 7.02 Application Procedures 21 Section 7.03 Process and Terms of Appointment 23 Section 7.04 Credentials Evaluation and Maintenance 24 1

2 TABLE OF CONTENTS CONT. Subject Page ARTICLE VII. CLINICAL PRIVILEGES 24 Section 8.01 General Provisions 24 Section 8.02 Process and Requirements for Requesting Clinical Privileges 25 Section 8.03 Process and Requirement for Requesting Renewal of Clinical Privileges 26 Section 8.04 Processing an Increase or Modification of Privileges 28 Section 8.05 Recommendation & Approval for Renewal & Revision of Clinical Privileges 28 Section 8.06 Exceptions 29 ARTICLE IX. INVESTIGATION AND ACTION 30 ARTICLE X. FAIR HEARING AND APPELLATE REVIEW 32 ARTICLE XI. RULES AND REGULATIONS 36 ARTICLE XII. AMENDMENTS 38 ARTICLE XIII. ADOPTION 39 2

3 PREAMBLE Recognizing that the Medical Staff is responsible for the quality of care delivered by its members and accountable to the Governing Body for all aspects of that care, the Medical Staff practicing at the Richard L. Roudebush VA Medical Center (RLR VAMC), Outpatient Centers and Domiciliary Unit hereby organizes itself for self-governance in conformity with the laws, regulations and policies governing the Department of Veterans Affairs, Veterans Health Administration (VHA), and the bylaws and rules hereinafter stated. These Bylaws and Rules are consistent with all laws and regulations governing the VHA, and they do not create any rights or liabilities not otherwise provided for in laws or VHA Regulations. DEFINITIONS For the purpose of these Bylaws, the following definitions shall be used: 1. Governing Body: The term Governing Body refers to the Under Secretary for Health, the individual to whom the Secretary for Veteran Affairs has delegated authority for administration of the Veterans Health Administration; and, for purposes of local facility management and planning has delegated authority to the Medical Center Director. 2. Medical Center Director: The Director (sometimes called Chief Executive Officer) is appointed by the Governing Body to act as its agent in the overall management of the Facility. The Director is assisted by the Chief of Staff (COS), the Associate Director (AD), the Associate Director for Patient Care Services (AD-PCS), and the Executive Committee of the Medical Staff. 3. Affiliation Partnership Council: A committee established by a formal memorandum of affiliation between the Roudebush VAMC and the Indiana University School of Medicine and approved by the Under Secretary for Health: composed of deans and senior faculty members of the affiliated medical, dental, nursing schools and other academic institutions as appropriate, representative(s) of the medical staff of the RLR VAMC; and such other faculty of the affiliated schools and staff of the RLR VAMC as are appropriate to consider and advise on development, management and evaluation of all educational, research, and clinical programs conducted at the facility. 4. Appointment: As used in this document, the term Appointment refers to appointment to the Medical Staff. It does not refer to appointment as a VA employee but is based on having an appropriate personnel appointment action, scarce medical specialty contract, or other authority to provide independent medical, Mid-level and/or patient care services at the facility. Both VA employees and contractors providing patient care services as licensed independent practitioner must receive appointments to the Medical Staff. 5. Practitioner: A physician, dentist, podiatrist, optometrist, psychologist or chiropractor who is fully licensed to practice in a State, Territory or Commonwealth of the U.S. or District of Columbia will be referred to as a Practitioner in these Bylaws. All other health professionals in the RLR VA Medical Center will practice under a position description, functional statement and/or scope of practice statement. 6. RLR VAMC Medical Center Memorandum (MCM): Local documents containing policy statements, supporting documentation and mandatory procedural material pertaining to the Richard L. Roudebush Veterans Administration Medical Center. The stated purpose must affect the entire facility; required by an accreditation or regulatory authority, Federal, State, local law or statute; required by the Medical Center Director; or failure to have a policy would result in significant increase of risks to patients, visitors, employees guests or facility infrastructure. 7. Medical Staff: Fully licensed independent physicians, dentists, psychologists, optometrists, podiatrists and chiropractors permitted by law and the Facility to provide patient care Services independently in the Facility, its satellite clinics and outreach facilities. 3

4 8. VA Regulations: The regulations set by Department of Veterans Affairs and made applicable to its entities in compliance with Federal laws. (Example: Code of Federal Regulation (CFR) ). 9. Proctoring: Proctoring is the activity by which a Practitioner is assigned to observe the practice of another Practitioner performing specified activities and to provide required reports on those observations. If the observing Practitioner is required to do more than just observe, i.e., exercise control or impart knowledge, skill or attitude to another Practitioner to ensure appropriate, timely and effective patient care, the action constitutes supervision. ARTICLE I. NAME The name of this organization shall be the Medical Staff of the Richard L. Roudebush VA Medical Center. ARTICLE II. The purposes of the Medical Staff shall be to: PURPOSE 1. Assure that all patients receive safe, efficient, timely, and appropriate care that is subject to continuous quality improvement practices. 2. Assure that all patients being treated for the same health problem or with the same methods/procedures receive the same level or quality of care. Primary care programs will assure continuity of care and minimize institutional care. 3. Establish and assure adherence to ethical standards of professional practice and conduct. 4. Develop and adhere to facility-specific mechanisms for appointment to the Medical Staff and delineation of clinical privileges. 5. Provide educational activities that relate to: care provided, findings of quality of care review activities, and expressed needs of caregivers and recipients of care. 6. Maintain a high level of professional performance of Practitioners authorized to practice in the facility through continuous quality improvement practices and appropriate delineation of clinical privileges. 7. Assist the Medical Center Director in developing and maintaining rules for Medical Staff governance and oversight. 8. Provide a medical perspective, as appropriate, to issues being considered by the Medical Center Director. 9. Develop and implement performance and safety improvement activities in collaboration with the staff and assume a leadership role in improving organizational performance and patient safety. 10. Provide channels of communication so that medical and administrative matters may be discussed and problems resolved. 11. Establish organizational policy for patient care and treatment and implement professional guidelines from the Under Secretary for Health, Veterans Health Administration. 12. Provide education and training, in affiliation with established programs, and assure that educational standards are maintained. The staff will cooperate with affiliated medical schools and other institutions of higher learning in undergraduate, graduate and postgraduate education in both medical and allied health education. The staff will encourage the intellectual interests of its members in basic and clinical research. Care will be taken to appropriately document supervision of resident physicians and other trainees. 4

5 13. Initiate and maintain an active continuous quality improvement program addressing all aspects of medical practice. Daily operations will be the subject of continuous quality improvement, as defined through organizational publications. ARTICLE III. MEDICAL STAFF MEMBERSHIP Section 3.01 Eligibility for Membership on the Medical Staff 1. Membership: Membership on the Medical Staff is a privilege extended only to, and continued for, professionally competent physicians, dentists, psychologists, podiatrists, optometrists and chiropractors who continuously meet the qualifications, standards, and requirements of VHA, this Facility, and these Bylaws. 2. Categories of the Medical Staff: a. Active staff who are employed by the VAMC on a half-time basis or greater or any who hold official administrative appointments. Attendance at medical staff meetings and respective service staff meetings is required for this category unless excused. Active staff members are expected to periodically participate in peer review activities, clinical committees and medical staff monitoring activities. b. Consulting staff members employed on a less than a half-time basis by any appropriate VA reimbursement mechanism or without compensation. These members are encouraged to attend meetings of the medical staff; however, attendance shall not be mandatory because of the frequently intermittent nature of their clinical activities at this hospital. c. Assigned duties from Section Chiefs and/or Service Chiefs are to be performed by all VAemployed physicians, both full-time and part-time. 3. Decisions regarding Medical Staff membership are made without discrimination for reasons such as race, color, religion, national origin, gender, sexual orientation, lawful partisan political affiliation, marital status, physical or mental handicap when the individual is qualified to do the work, age, membership or non-membership in a labor organization, or on the basis of any other criteria unrelated to professional qualifications. Section 3.02 Qualifications for Medical Staff Membership and Clinical Privileges 1. Criteria: To qualify for Medical Staff membership and clinical privileges, individuals who meet the eligibility requirements identified in Section 3.01 must submit evidence as listed below. Applicants not meeting these requirements will not be considered. This determination of ineligibility is not considered a denial: a. Active, current, full and unrestricted license to practice individual's profession in a state, territory or commonwealth of the United States or the District of Columbia as required for appointment under applicable employment authorities. b. Education applicable to individual Medical Staff members as defined, for example holding a Doctoral level degree in Medicine, Osteopathy, or Dentistry from an approved college or university. c. Relevant training and/or experience consistent with the individual's professional assignment and the privileges for which he/she is applying. This may include any internship, residencies, fellowships, board certification, and other specialty training. d. Current competence, consistent with the individual's assignment and the privileges for which he/she is applying. 5

6 e. Health status consistent with physical and mental capability of satisfactorily performing the duties of the Medical Staff assignment within clinical privileges granted. f. Complete information consistent with requirements for application and clinical privileges as defined in Articles VII or VIII or of these Bylaws for a position for which the facility has a patient care need, and adequate facilities, support services and staff. g. Satisfactory findings relative to previous professional competence and professional conduct. h. English language proficiency. i. Current professional liability insurance as required by Federal and VA acquisition regulations for those individuals providing service under contract. j. A current picture hospital ID card or a valid picture ID issued by a state or federal agency (e.g. driver s license or passport) k. Participate in continuing education. l. Reside in a geographic location within a reasonable commuting time, as applicable for those individuals to be appointed to the active medical staff, half time or greater. m. Background Screening: Applicant must complete fingerprinting and initiate a U.S. Office of Personnel Management background screening for medical staff appointment at the Roudebush VA Medical Center. A grace period of 60 days from initial appointment date and the granting of clinical privileges will be allowed to initiate the background screening process. The applicant will be notified of any discrepancies or adverse reports discovered from the background screening by Human Resource Management Service. 2. Clinical Privileges and Scopes of Practice: While only Licensed Independent Practitioners may function with defined clinical privileges, not all Licensed Independent Practitioners are permitted by this Facility and these Bylaws to practice independently. a. The following Practitioners will be credentialed and privileged to practice independently and serve as members of the medical staff: i) Physicians ii) Dentists iii) Psychologists iv) Podiatrists v) Optometrists vi) Chiropractors b. Health care professionals enrolled in an a professional training program may be appointed and granted clinical privileges or scope of practice to function outside of their training program in a field for which they meet competency and qualification standards. The appointment must not violate their training program requirements. c. Health care practitioners functioning solely as Lecturer, Researcher, or Instructor, who are not providing or responsible for patient care, must apply and be approved for a Medical Staff appointment. Clinical privileges are not required for these occupations. d. The following practitioners will be credentialed and will practice within a Collaborative Practice Agreement or Scope of Practice with a fully credentialed and clinically privileged medical staff member at this facility: i) Advanced Practice Nurses Reference RLR VAMC Medical Center Memorandum ii) Physician Assistants Reference RLR VAMC Medical Center Memorandum 6

7 e. All other licensed, registered or certified health care practitioners will be credentialed, as per VHA Directive , and will practice under a scope of practice or position description with appropriate supervision. This includes health care practitioners and all Research personnel who are hired into an occupation requiring licensure, professional certification or registration.. f. Change in Status: Practitioners must agree to provide care to patients within the scope of their delineated Clinical Privileges, Collaborative Practice Agreement or Scopes of Practice and advise the Medical Center Director, through the Chief of Staff, of any change in ability to fully meet the criteria for Medical Staff membership, the ability to carry out clinical privileges or functions which are held. Advise the Medical Center Director through the Chief of Staff of any challenges or claims against professional credentials, professional competence or professional conduct and any felony criminal convictions or health issues that could affect professional performance as soon as possible, but no longer than 15 days of knowledge of such occurrences after notification of the practitioner. The practitioner applying for a change in appointment status, such as part-time to full time or contract to Federal employee, will be required to submit a new Supplemental Attestation via the VetPro electronic credentialing system. Section 3.03 Code of Conduct 1. Acceptable Behavior: The VA expects that members of the medical staff will serve diligently, loyally, and cooperatively. They must avoid misconduct and other activities that conflict with their duties; exercise courtesy and dignity; and otherwise conduct themselves, both on and off duty, in a manner that reflects positively upon themselves and VA. Acceptable behavior includes the following (1) being on duty as scheduled. (2) being impartial in carrying out official duties and avoiding any action that might result in, or look as though, a medical staff member is giving preferential treatment to any person, group or organization, (3) not discriminating on the basis of race, age, color, sex, religion, national origin, politics, marital status, or disability in any employment matter or in providing benefits under any law administered by VA, (4) not making a governmental decision outside of official channels, (5) not taking any action that impedes government efficiency and economy, affects one s impartiality, or otherwise lowers public confidence in the Federal Government, and (6) with certain exceptions in accordance with 5 C.F.R. 2635, not asking for or accepting any gift, tip, entertainment, loan, or favor, or anything of monetary value for oneself or any member of one s family from any person or organization that is seeking or has a business or financial relationship with the VA to avoid the appearance that one s official actions might be influenced by such gifts. Reference RLR VAMC Medical Center Memorandum, Conflict of Interest. 2. Behavior or Behaviors That Undermine a Culture of Safety: VA recognizes that the manner in which its Practitioners interact with others can significantly impact patient care. VA strongly urges its providers to fulfill their obligations to maximize the safety of patient care by behaving in a manner that promotes both professional practice and a work environment that ensures high standards of care. The Accreditation Council for Graduate Medical Education highlights the importance of interpersonal/communication skills and professionalism as two of the six core competencies required for graduation from residency. Providers should consider it their ethical duty to foster respect among all health care professionals as a means of ensuring good patient care. Conduct that could intimidate others to the extent that could affect or potentially may affect quality and safety will not be tolerated. These behaviors, as determined by the organization, may be verbal or non-verbal, may involve the use of rude and/or disrespectful language, may be threatening, or may involve physical contact. Behavior or Behaviors That Undermine a Culture of Safety is a style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care. Furthermore, it has become apparent that behavior or behaviors that 7

8 undermine a culture of safety is often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, behavior or behaviors that undermine a culture of safety may reach a threshold such that it constitutes grounds for further inquiry by the Medical Executive Committee into the potential underlying causes of such behavior. Behavior by a provider that is disruptive could be grounds for disciplinary action. VA distinguishes behavior or behaviors that undermine a culture of safety from constructive criticism that is offered in a professional manner with the aim of improving patient care. VA also reminds its providers of their responsibility not only to patients, but also to themselves. Symptoms of stress, such as exhaustion and depression, can negatively affect a provider s health and performance. Providers suffering such symptoms are encouraged to seek the support needed to help them regain their equilibrium. Providers, in their role as patient and peer advocates, are obligated to take appropriate action when observing behavior or behaviors that undermine a culture of safety on the part of other providers. VA urges its providers to support their hospital, practice, or other healthcare organization in their efforts to identify and manage behavior or behaviors that undermine a culture of safety, by taking a role in this process when appropriate. Reference RLR VAMC Medical Center Memorandum, Health Status and Impaired Professional Program. 3. Professional Misconduct: Behavior by a professional that creates the appearance of a violation of ethical standards or has compromised ethical standards will not be tolerated. Reference RLR VAMC Medical Center Memorandum, Integrated Ethics. 1. Composition: a. Chief of Staff b. Assistant Chief of Staff c. Clinical Service Chiefs d. Secretary e. Secretary-Elect 2. Selection: ARTICLE IV: ORGANIZATION OF THE MEDICAL STAFF Section 4.01 Leaders a. Chief of Staff will be appointed by VA Central Office upon recommendation of the Medical Center Director in accord with VA policy and regulations. b. Assistant Chief of Staff will be appointed with recommendation by the Chief of Staff and approved by the Medical Center Director. c. Clinical Service Chiefs will be appointed with recommendation from VA Central Office by the Medical Center Director in accord with VA policy and regulations. d. The Secretary, Secretary-elect shall be elected by the membership of the Medical Staff. The term of office for the Secretary and Secretary-elect shall be one year (October 1 to September 30) and the Secretary-elect shall succeed the Secretary. Qualifications for the Secretary and Secretary-elect include: completion of an approved residency, staff membership in a non-centralized position for at least one year, an appointment that is 5/8's or greater, regardless of method of remuneration, and active participation in patient care and 8

9 teaching program. At the time of election, the Secretary will not be eligible as a candidate for Secretary-elect. e. The annual election will take place at a Medical Staff meeting. f. A nominating committee will be appointed by the Secretary prior to the election, composed of at least three, 4/8's time or greater, members of the Medical Staff who hold non-centralized positions. g. The nominating committee will develop a slate of at least two candidates for the office of Secretary-elect. The slate of candidates will be submitted to the membership prior to the June meeting. h. This will not preclude nominations from the floor at the time of election nor by petition of members of the Medical Staff. i. The candidate with greatest number of votes will be elected. j. In the event of resignation, transfer, etc., of the Secretary or Secretary-elect, the nominating committee will develop a slate of candidates for the next staff meeting or the vacancy will be filled through a new election accomplished by a mail-out ballot. The Secretary-elect will succeed early to fill the unexpired term of the Secretary. 3. Removal of Officers a. Officers of the Medical Staff will be accorded due process in removal proceedings. Actions to remove officers of the Medical Staff will be carried out in accordance with applicable VA Policy and Regulation. b. Proposals to remove an officer of the Medical Staff will be processed concurrent with and in accordance with VA Policy as outlined in VA Manual Procedures as outlined in VA Handbook 5019/2, Part III and VA Handbook 5021 & VA Directive c. Elected Officers - Upon petition to the Medical Center Director by 25% of the voting members of the Medical Staff, a recall election by secret ballot will be held within ten (10) days. Greater than two-thirds majority is necessary to remove such an elected officer. In the event of a sustained recall, the remainder of the elected officer s term will be completed by the Medical Staff member next scheduled to serve in that office. This event will not affect the subsequent term for which the officer was elected. d. Questions should be referred to the VHA Office of Quality, Safety & Value; the Office of Human Resources Management, VACO; or the Office of Regional Counsel. 4. Responsibility a. Medical Staff members should become knowledgeable of this process and applicable VA Policy and regulations as related to membership and removal of elected officers. b. Medical Staff members are responsible for adhering to this process in considering or recommending removal of any officer. c. The Medical Center Director is responsible for appropriate coordination and actions when considering or processing a proposed removal of a medical staff officer. 5. Duties: a. The Chief of Staff shall serve as the Chief Administrative Officer of the Medical staff according to VA regulations to: 9

10 (1) Act in coordination and cooperation with the Medical Center Director in all matters of mutual concern within the medical center; (2) Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff; (3) Serve as Chair of the Executive Committee of the Medical Staff; (4) Be responsible for the enforcement of Medical Staff Bylaws, rules and regulations, in collaboration with the chiefs of the clinical services; (5) Appoint committee members to all standing, special and multidisciplinary medical staff committees with the advice and consent of the Secretary of the Medical Staff, except the Executive Committee of the Medical Staff; (6) Represent the views, policies, needs and grievances of the medical staff to the Medical Center Director; (7) Receive and interpret the policies of the Medical Center Director to the medical staff and report to the Medical Center Director on the performance and maintenance of quality with respect to the medical staff's delegated responsibility to provide medical care; (8) Be responsible through the Associate Chief of Staff for Research and Chief Education Officer for the research and educational activities of the Medical Staff, and relations. (9) Be spokesperson for the Medical Staff in its external, professional and public b. The Secretary of the Medical Staff shall: (1) serve as a member of the ECMS/Professional Standards Board; (2) serve as Vice-Chair of the Executive Committee of the Medical Staff; (3) advise and consent to the appointment of committee members to all standing, special and multidisciplinary Medical Staff committees with the exception of the Executive Committee of the Medical Staff; (4) assist the Chief of Staff in representing the views, policies, needs and grievances of the Medical Staff to the Medical Center Director; c. The Secretary-elect of the Medical Staff shall: (1) assume all the duties of the Secretary in the absence of the Secretary; (2) perform other duties as requested by the Secretary; (3) serve as a member-at-large of the Executive Committee of the Medical Staff. Section 4.02 Leadership 1. The Organized Medical Staff, through its committees and Service Chiefs, provides counsel and assistance to the Chief of Staff and Director regarding all facets of patient care, treatment, and services including evaluating and improving the quality and safety of patient care services. The administrative organization of the medical staff shall follow VA regulations. 10

11 1. Characteristics: Section 4.03 Clinical Services a. Clinical Services are organized to provide clinical care and treatment under leadership of a Service Chief. b. Clinical Services hold service-level meetings at least at least quarterly. 1. Functions: a. Provide for quality and safety of the care, treatment, and services provided by the Service. This requires ongoing monitoring and evaluation of quality and safety, (including access, efficiency, and effectiveness); appropriateness of care and treatment provided to patients; patient satisfaction activities; patient safety and risk management activities; and utilization management. b. Provides referral, transfer or discharge of patients to another level of care, health professional or setting, based on the patient s assessed needs and the hospital s capacity to provide the care. c. Assist in identification of important aspects of care for the Service, identification of indicators used to measure and assess important aspects of care, and evaluation of the quality and appropriateness of care. Utilize VHA performance measures and monitors as a basis for assessing the quality, timeliness, efficiency, and safety of Service activities. d. Maintain records of meetings that include reports of conclusions, data, recommendations, responsible person, actions taken, and an evaluation of effectiveness of actions taken. e. Develop criteria for recommending clinical privileges for members of the Service and ensure that ongoing professional practice evaluation is continuously performed and results are utilized at the time of re-privileging. f. Define and/or develop clinical privilege statements including levels (or categories) of care that include all requirements of VHA Handbook g. Develop policies and procedures to assure effective management, ethics, safety, communication, and quality within the Service. h. Annually review privilege templates for each Service/Section to determine whether sufficient space, equipment, staffing, and financial resources are in place, or available within a specified time frame, to support the privilege delineation and make recommendations to the Executive Committee of the Medical Staff. i. Each of the clinical Services shall conduct meetings at least quarterly to consider findings from ongoing monitoring and evaluation of the quality and appropriateness of patient care and treatment. Minutes must reflect discussion by medical staff and responsible party of patient care issues, with resultant significant conclusions, recommendations, action taken, and evaluation of follow-up actions. 2. Selection and Appointment of Service Chiefs: Service Chiefs are appointed by the Medical Center Director based upon the recommendation of the Chief of Staff and Affiliation Partnership Council. Service Chiefs must hold certification by an appropriate specialty board or comparable competence affirmatively established through the credentialing process. 3. Duties and Responsibilities of Service Chiefs: The Service Chief is administratively responsible for the operation of the Service and its clinical and research efforts, as appropriate. In addition to duties listed below, the Service Chief is responsible for assuring the Service performs according to applicable VHA performance standards. These requirements are described in individual Performance Plans for each Service Chief. Service Chiefs are responsible and accountable for: 11

12 a. Completing Medical Staff Leadership and Provider Profiling on-line training within three months of appointment as Service Chief. b. Clinically related activities of the Service. c. Administratively related activities of the department, unless otherwise provided by the organization. d. Continued surveillance of the professional performance of all individuals in the Service who have delineated clinical privileges. Reference Medical Center Memorandum, Professional Practice Evaluation. e. Assuring that individuals with clinical privileges provide service within the scope of privileges granted. f. Recommending to the medical staff the criteria for clinical privileges that are relevant to the care provided in the Service. g. Recommending clinical privileges for each member of the Service. h. Assessing recommendations for off-site sources of needed patient care, treatment, and services not provided by the Service and communicating the recommendations to the relevant organizational authority. i. The integration of the Service into the primary functions of the organization. j. The coordination and integration of interdepartmental and intradepartmental services. k. The development and implementation of policies, Medical Center Memorandum, and procedures that guide and support the provision of care, treatment, and services. l. The assurance of a sufficient number of qualified and competent persons to provide care, treatment, and service. m. The determination of the qualifications and competence of service personnel who are not licensed independent Practitioners and who provide patient care, treatment, and services. n. The continuous assessment and improvement of the quality of care, treatment, and services. o. The maintenance of and contribution to quality control programs, as appropriate. p. The orientation and continuing education of all persons in the service. q. The assurance of space and other resources necessary for the service defined to be provided for the patients served. r. Annual review of all clinical privilege forms to ensure that they correctly and adequately reflect the services being provided at the facility. This review is noted by date of review being included on the bottom of each privilege delineation form. 1. Committees are either standing or special. ARTICLE V. MEDICAL STAFF COMMITTEES Section 5.01 General 2. All committee members, regardless of whether they are members of the Medical Staff, are eligible to vote on committee matters unless otherwise set forth in these Bylaws. 3. The presence of 25% of a committee s members will constitute a quorum. 12

13 4. Membership Recommendation for committee membership may come from the committee itself to the Chief of Staff and Secretary of the Medical Staff. The Secretary of the Medical Staff will advise and consent to the appointment of committee members to all standing, special and multidisciplinary Medical Staff committees with the exception of the Executive Committee of the Medical Staff. Establishment of new Medical Staff committees will be presented to the Executive Committee of the Medical Staff for recommendation to the Medical Center Director for approval. 5. Recommendation to remove a member of a committee may be proposed to the Chairman, accepted by the majority of members of that committee and removal concurred by the Chief of Staff and Medical Center Director. 6. Unless otherwise set forth in these Bylaws, the Chair of each committee is appointed by the Chief of Staff. Section 5.02 Executive Committee of the Medical Staff (ECMS) 1. Membership: Incumbents of the following positions will serve as members of the Executive Committee of the Medical Staff. This membership may be expanded as needed by a majority vote of the Committee and the concurrence of the Chief of Staff and Medical Center Director. Chief of Staff Associate Chief of Staff Chief, Ambulatory Care Service Associate Chief of Staff for Research Associate Director for Patient Care Services Assistant Chief of Staff Chief, Anesthesia Service Chief, Compensation & Pension Service Chief, Dental Service Chief, Division of General Internal Medicine Chief, Medicine Service Chief, Neurology Service Chief, Pathology/Laboratory Medicine Service Chief, Physical and Rehabilitation Medicine Chief, Psychiatry & Mental Health Service Chief, Radiology Service Chief, Radiation/Oncology Service Chief, Surgery Service Emergency Department Director Medical Staff Secretary Medical Staff Secretary-Elect Hospital Quality Manager Chair, Voting Member Voting Member Voting Member Voting Member on issues related to nursing patient care services and nurse credentialing Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Voting Member Non-Voting Member 13

14 Medical Center Director or Designee Chief Education Officer Regional Counsel or Designee Chief, Pharmacy Service Advanced Practice Nurse * Approving Official Non-Voting Member Non-Voting Member Non-Voting Member *Advanced Practice Nurse (APN) representatives will be recommended from the Advanced Practice Committee in the Medical Center. One APN will serve as a Non-Voting Member At-large at ECMS meetings. A second APN will serve as a Voting Member on the Executive Committee of the Medical Staff/Professional Standards Board who attends and votes on matters related to APN Clinical Function Collaborative Practice Agreements. 2. Functions of the Executive Committee of the Medical Staff a. Acts on behalf of the Medical Staff between Medical Staff meetings. b. Voting members maintain process for reviewing credentials and delineation of clinical privileges and/or collaborative agreements to ensure authenticity and appropriateness of the process in support of clinical privileges and/or collaborative agreements requested; to address the scope and quality of services provided within the facility. c. Acts to ensure effective communications between the Medical Staff and the Director. d. The ECMS will ensure that reviews of functional areas listed below are accomplished, meeting all steps of the Quality Management process or other applicable standards. These reviews will be used in monitoring the quality and appropriateness of patient care delivered. The Office of Quality Management will provide staff support to the ECMS in accomplishing this responsibility. Service Chiefs, Committee Chairpersons, and other responsible individuals will assure that all performance improvement activity is adequately and timely documented in meeting minutes. The ECMS has oversight over, but not limited to, the following functional areas: Autopsy Review Blood Usage Review Committee Cancer Committee Contracted Clinical Services Critical Care Committee Infection Control Committee Medical Records Review Medical & Radiological Invasive Procedure Review Pharmacy, Therapeutics & Nutrition Committee Radionuclide Safety Committee Research and Development Committee Resident Supervision Reusable Medical Equipment Committee Risk Management Operative/Other Invasive and Non-Invasive Procedures Review Utilization Review Peer Review for Quality Management e. Makes recommendations directly to the Medical Center Director regarding the: (1) Organization, membership, structure and function of Medical Staff 14

15 (2) Process used to review credentials and to delineate clinical privileges (3) Individuals for Medical Staff membership (4) Delineated clinical privileges, including Admitting privileges, for each eligible practitioner and clinical functions for Advanced Practice Nurses and Physician Assistants (5) Organization of performance improvement activities of Medical Staff as well as mechanism used to conduct, evaluate, and revise such activities (6) Process by which membership on Medical Staff may be terminated, consistent with applicable laws and VA regulations. (7) Process for fair-hearing procedures, consistent with applicable laws and VA regulations. f. Coordinates the ongoing review, evaluation, and quality improvement activities and ensures full compliance with Veterans Health Administration Clinical Performance Measures, The Joint Commission, and relevant external standards. g. Voting members oversee processes in place for instances of for-cause concerning a medical staff member s competency to perform requested privileges. h. Voting members oversee the process by which membership on the medical staff may be terminated consistent with applicable laws and VA regulations. i. Voting members oversee the process for fair-hearing procedures consistent applicable laws and VA regulations. j. Voting members monitor medical staff ethics and self-governance actions. k. Advises facility leadership and coordinates activities regarding clinical policies, clinical staff recommendations, and accountability for patient care through the Clinical/Performance Board. l. Receives and acts on reports and recommendations from medical staff committees including those with quality of care responsibilities, clinical services, and assigned activity groups and makes needed recommendations to the Governing Body. m. Assists in development of methods for care and protection of patients and others at the time of internal and external emergency or disaster, according to VA policies. n. Acts as and carries out the function of the Medical Staff Professional Standards Board by its voting members, which includes review and recommendation of medical staff appointment, delineation of clinical privileges and collaborative practice agreements for Advanced Practice Nurses and Physician Assistants. Reviews and makes recommendation regarding disciplinary and adverse actions to the Medical Center Director. o. Provides oversight and guidance for fee basis/contractual services. p. Annually reviews and makes recommendations for approval of the Service-specific privilege lists and ongoing professional performance evaluation criteria. q. Voting physician members act as and carry out the function of the Physical Standards Board, Reference RLR VAMC Medical Center Memorandum, which include: (1) The evaluation of physical and mental fitness of all medical staff upon referral by the Occupational Health Physician. (2) Determine whether VHA personnel are physically and/or mentally suitable for appointment or retention in VA employment. 15

16 (3) The Employee Health Physician may perform physical examinations. All examinations of a questionable nature not resolved by appropriate consultation will be referred to the Physical Standards Boards. 3. Meetings: a. Regular Meetings: Regular meetings of the Executive Committee of the Medical Staff (ECMS) shall be held at least ten times per year. The date and time of the meetings shall be established by the Chair for the convenience of the greatest number of members of the Committee. The Chairpersons of the various committees of the Medical Staff shall attend regular meetings of the Executive Committee of the Medical Staff, when necessary, to report the activities and recommendations of their committees; and may attend at other times with the consent of the Chief of Staff. Such attendance shall not entitle the attendee to vote on any matter before the Executive Committee of the Medical Staff. b. Emergency Meetings: Emergency meetings of the Executive Committee of the Medical Staff may be called by the Chief of Staff to address any issue which requires action of the Committee prior to a regular meeting. The agenda for any emergency meeting shall be limited to the specific issue for which the meeting was called, and no other business may be taken up at an emergency meeting. In the event that the Chief of Staff is not available to call an emergency meeting of the Executive Committee of the Medical Staff, the Director as the Governing Body, Acting Chief of Staff or Secretary of the Medical Staff, may call an emergency meeting of the Committee. c. Meeting Notice: All Executive Committee of the Medical Staff members shall be provided advanced notice, written or , of the time, date, and place of each regular meeting and reasonable notice of each emergency meeting. d. Agenda: The Chief of Staff, or in his absence, the Acting Chief of Staff or Secretary to the Medical Staff shall Chair the Executive Committee of the Medical Staff. The Chair shall establish the agenda for all meetings, and a written or electronic agenda shall be prepared and distributed prior to committee meetings. e. Quorum: A quorum for the conduct of business at any regular or emergency meeting of the Executive Committee of the Medical Staff shall be 25% of the voting members of the committee. Action may be taken by majority vote at any meeting or via electronic vote by members. The majority of the voting members must be fully licensed physicians of medicine or osteopathy. f. Minutes: Written minutes shall be made and kept on all meetings of the Executive Committee of the Medical Staff, and shall be open to inspection by Practitioners who hold membership or privileges on the Medical Staff. g. Communication of Action: The member or representative proposing a recommendation or action at a meeting of the Executive Committee of the Medical Staff is responsible for communicating such action to any person who is directly affected by it. 4. Conflict Management: a. When the ECMS prepares to adopt a new rule or regulation, or a revision or deletion to an existing rule or regulation of the Medical Staff, these proposals will be forwarded to the voting 16

17 members first for their review and comment before submitting a final recommendation to the Medical Center Director. b. Medical Staff members are notified via of changes in policy or regulation. c. Medical Staff members may voice their concerns with proposed or completed actions of the ECMS to the Secretary of the Medical Staff, Chief of their clinical Service or Chief of Staff. These suggestions or concerns will be brought to the ECMS for review and discussion. At the discretion of the Chief of Staff, the member or members may be invited to the ECMS to express their views or concerns in person. d. If there is conflict between the Medical Staff and leadership groups of the Medical Center, the Medical Center leadership facilitates management of the conflict through Human Resource representatives or others who have the required skills and expertise for such facilitation. Section 5.03 Committees of the Medical Staff 1. The following Standing Committees hereby are established for the purpose of (a) evaluating and improving the quality of health care rendered, (b) reducing morbidity or mortality from any cause or condition, (c) establishing and enforcing guidelines designed to keep the cost of health care within reasonable bounds (d) reporting variances to accepted standards of clinical performance by, and in some cases to, individual Practitioners and (e) for such additional purposes as may be set forth in the charges to each committee. 2. Medical Staff Committees include but are not limited to the following. Additional committees along with local policies, rules and regulations are outlined and defined in RLR VAMC Medical Center Memorandums and service level policy: a. Operative/Other Invasive and Non-OR Invasive procedures review is performed at least quarterly by those departments/ services performing surgical and non-invasive procedures or by a Medical Staff committee to help assure that surgery and non-or invasive procedures performed in the hospital are justified and of high quality. The review process is outlined in RLR VAMC Medical Center Memorandum. b. Drug Usage Evaluation is performed by the Medical Staff as a criteria-based, ongoing, planned and systematic process for monitoring and evaluating the prophylactic, therapeutic, and empiric use of drugs to help assure that they are provided appropriately, safely, and effectively. Activities are guided by the Pharmacy, Nutrition and Therapeutics Committee as outlined in RLR VAMC Medical Center Memorandum. c. Pharmacy and Therapeutics function is performed by the Medical Staff, in cooperation with Pharmacy Service, Patient Care Services, other management and administrative services. Refer to RLR VAMC Medical Center Memorandum and VISN Policy. d. Medical Record Review at the point of care are performed at or after the point of care for elements determined at the discretion of the Medical Staff and Medical Center leadership with the defined elements being reviewed no less than annually. e. Blood Usage Review is performed by the Transfusion Review Committee, Reference RLR VAMC Medical Center Memorandum. 17

18 f. The Medical Staff participates in other review functions including internal and external disaster plans. g. The Medical Staff actively participates, as appropriate, in the following Risk Management and Patient Safety activities related to the clinical aspects of patient care: (1) The identification of general areas of potential risk in the clinical aspects of patient care and safety; (2) The development of criteria for identifying specific cases with potential risk in the clinical aspects of patient care and safety, and evaluation of these cases; (3) The correction of problems in the clinical aspects of patient care and safety identified by risk management activities; and (4) The design of programs to reduce risk in the clinical aspects of patient care and safety. (5) Provision for special procedures with intent of minimizing risk to patients such as, but not limited to, use of restraints, seclusion, moderate sedation. h. The effectiveness of all functions the monitoring and evaluation of the quality and appropriateness of patient care provided by all individuals with clinical privileges/clinical functions, invasive and non-invasive procedures, drug usage evaluation, the medical record review function, blood use review, the pharmacy, nutrition and therapeutics functions, and other review functions is evaluated as part of the annual reappraisal of the medical center s performance improvement program. Information Flow to Executive Committee of the Medical Staff: All Medical Staff Committees, including but not limited to those listed above, will submit minutes of all meetings to the Executive Committee of the Medical Staff on a quarterly basis after the minutes are approved and will submit such other reports and documents as required and/or requested by the Executive Committee of the Medical Staff. Section 5.04 Committee Records and Minutes 1. Committees prepare and maintain reports to include data, conclusions, recommendations, responsible person, actions taken, and evaluation of results of actions taken. These reports are to be forwarded in a timely manner through clinical service chiefs or as outlined in RLR VAMC Medical Center Memorandum, at a minimum on a quarterly basis. 2. Each Committee provides appropriate and timely feedback to the Services relating to all information regarding the Service and its providers. 3. Each committee shall review and forward to the Executive Committee of the Medical Staff a synopsis of any subcommittee and/or workgroup findings. Section 5.05 Establishment of Committees 1. The Executive Committee of the Medical Staff may, by resolution and upon approval of the Director, without amendment of these Bylaws, establish additional standing or special committees to perform one or more Medical Staff functions. 2. The Executive Committee of the Medical Staff may, by resolution and upon approval of the Director, dissolve or rearrange committee structure, duties, or composition as needed to better accomplish Medical Staff functions. 18

19 ARTICLE VI. MEDICAL STAFF MEETINGS 1. Regular Meetings: Regular meetings of the Medical Staff as a whole shall be held at least annually. A record of attendance shall be kept. 2. Special Meetings: Special meetings of the Medical Staff may be called at any time by the Chief of Staff or at the request of the Director or the Executive Committee of the Medical Staff. At any such meeting, only that business set forth in the notice thereof will be transacted. Notice of any such meeting will be given in writing or via electronic message to the Medical Staff. Members of the Medical Staff may request a special meeting either through the Chief of Staff or Director in writing or via electronic message and stating the reason(s) for the request. 3. Quorum: For purposes of Medical Staff business, twenty-five (25) percent of the Active medical staff membership constitutes a quorum. Absentee ballots may be counted to approve policies such as changes in Bylaws, Rules and Regulations. 4. Meeting Attendance: Members of the Active Medical Staff (5/8ths time or greater) are expected to attend regular Medical Staff meetings and Service-level meetings. Excused absences should be documented. ARTICLE VII. APPOINTMENT AND ONGOING CREDENTIALING Section 7.01 General Provisions 1. Independent Entity: The Roudebush VA Medical Center is an independent entity, granting privileges to the medical staff through the Executive Committee of the Medical Staff and Governing Body as defined in these Bylaws. Credentialing and privileging are performed prior to initial appointment. Medical Staff reappointments may not exceed 2 years, minus one day from the date of last appointment or reappointment date. Advanced Practice Nurses and Physician Assistants must practice under a scope of practice or collaborative practice agreement. 2. Credentials Review: All Licensed Independent Practitioners (LIP), Advanced Practice Nurses and Physician Assistants who hold clinical privileges, collaborative practice agreements or scopes of practice will be subjected to full credentials review at the time of initial appointment, at the time of reappraisal (not greater than a 2 year period), and after a break in service. Credentials that are subject to change during leaves of absence shall be reviewed at the time the individual returns to duty. Practitioners applying for a change in appointment status, such as part-time to full time or contract to Federal Employee, will be required to submit a new VetPro Supplemental Questionnaire, reporting full details of any positive response given. 3. Deployment/Activation Status: a. When a member of the medical staff has been deployed to active duty, upon notification, the privileges will be placed in a Deployment/Activation Status and the credentialing file will remain active. Upon return of the Practitioner from active duty, in accordance with the Uniformed Services Employment and Reemployment Rights Act of l994 (USERRA), the Practitioner will update the credentialing file to current status. b. After verification of the updated information is documented, the information will be referred to the Practitioner s Service Chief then forwarded to the Executive Committee of the Medical Staff for recommendation to restore privileges to active, current status, based on evidence of current competence. Special circumstances may warrant the Service Chief and Executive Committee to put an FPPE in place to support current competence. The Director has final approval for restoring privileges to active and current status. 19

20 c. In those instances where the privileges lapsed during the call to active duty, the Practitioner must provide additional references or information needed for verification and all verifications must be completed prior to reappointment. d. In those instances where the Practitioner was not providing clinical care while on active duty, the Practitioner in cooperation with the Service Chief must consider the privileges held prior to the call to active duty and whether a request for modification of these privileges should be initiated, on a short-term basis. These providers may be returned to a pay status, but may not be in direct patient care. 4. Employment or Contract: Appointments to the Medical Staff occur in conjunction with VHA employment or under a VHA contract or sharing agreement. The authority for these actions is based upon: a. Provisions of 38 U.S.C in accordance with VA Handbook 5005, Part II, Chapter 3, VHA Handbooks and applicable Agreement(s) of Affiliation in force at the time of appointment. b. Federal law authorizing VA to contract for health care services. 5. Initial Focused Professional Practice Evaluation: a. The initial focused professional practice evaluation (FPPE) is a process whereby the Medical Staff evaluates the privilege-specific competence of a Practitioner who does not have documented evidence of competently performing the requested privilege at the organization. This occurs with a new Practitioner or an existing Practitioner who requests a new privilege. The performance monitoring process is outlined in RLR VAMC Medical Center Memorandum, Professional Practice Evaluation. b. The FPPE is separate and distinct from the Human Resource probationary review. (1) Initial and certain other appointments made under 38 U.S.C. 7401(l), 7401(3), 5 U.S.C are probationary. During the probationary period, professional competence, performance, and conduct will be closely evaluated under applicable VA policies, procedures, and regulations. If, during this period, the employee demonstrates an acceptable level of performance and conduct, the employee will successfully complete the probationary period. c. Successful completion of the FPPE does not equate to successful completion of a probationary period. 6. Ongoing Professional Practice Evaluation: a. The on-going monitoring of privileged practitioners is essential to confirm the quality of care delivered. This is called the Ongoing Professional Practice Evaluation (OPPE). This allows the facility to identify professional practice trends that impact the quality of care and patient safety. Reference RLV VAMC Medical Center Memorandum, Professional Practice Evaluation. b. In considering the reappointment of staff who have not practiced at this facility in the past two years and pursuant to the requirement that practitioner specific performance improvement data be reviewed as part of the credentialing process, a practitioner may be reappointed based on a peer recommendation from the individual s supervisor (i.e., Chairman, Service/Department Head) from the institution where the individual actively practices in order to support the request for clinical privileges and medical staff membership. The acceptability of such external data shall be at the discretion of the Executive Committee of the Medical Staff. It is anticipated that the substitution of external data will apply only to those individuals who conduct the greater majority of their practice outside of the Medical Center. 20