Volume 5 | Issue 12
Inside This Issue
Claudia Lucchinetti Appointed Senior Vice President for Medical Affairs at UT Austin & Dean of Dell Medical School See pg. 10
INDEX Oncology Research......... pg.3 The Framework.................... pg.6 Healthy Heart....................... pg.8 Age Well Live Well........... pg.12
UT Southwestern Researchers Identify a Regulator of Breast Cancer Development See pg. 11
Medical Staff Organizations – Five Things You Should Do
By Sherri T. Alexander, J.D. Erin Muellenberg, J.D. Polsinelli, PC
H
ospitals and medical staffs are highly regulated organizations with a myriad of laws and standards that must be followed. Medical staff leaders, advisors or medical staff professionals are responsible for leading and advising the professionals who are responsible for practitioner competence and conduct within the organization. As the year-end approaches, it is a good time for these individuals to evaluate the effectiveness of the peer review process and reflect on the related protections and obligations. Below are five recommendations for a medical staff organization’s year-end review and reflection. 1. Update Governance Documents to Reflect Actual Practice. Governance documents include the medical sta f f bylaws, credentialing manual, hearing plan, rules and regulations, policies and other documents approved by the medical staff and designed to set and guide medical staff processes. Too often these documents will conflict or omit critical passages. All governance documents should be reviewed in the context of the laws and regulations that require these documents. State and federal laws and regulations set out the basic
requirements for the contents of the documents, as do many of the accreditation standards. It is far
on behalf of the committee/ department between meetings. Do what is needed when needed, within the scope of your authority, but report your actions to the committee/ department on a regular basis and be sure your actions are properly recorded in the appropriate minutes. If summary or urgent action is needed, do not hesitate to call a special meeting. You are better off to have the protection of a committee action than to be acting alone or without ratification. Know the Peer Review Protections of HCQIA, Texas and Organization. The Healthcare Q u a lit y Improvement Act (“HCQIA”) provides protection from liability for members of a professional review body/ medical staff, who take a professional
Medical staff organizations serve a very important role. Regularly reviewing governance documents and legal protections are vital to promoting and maintaining quality health care within an organization. better to review and revise your governance documents regularly, rather than learn they are deficient during an unannounced survey or regulatory proceeding. 2. Know the Scope of Your Authority. Medical staff bylaws generally identify the circumstances under which you can act alone and when your action(s) will need to be ratified by the committee. As the chair, you are acting
see Five Things...page 14
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